Provider Demographics
NPI:1295860039
Name:LAMBERTH, SHANNON FAYE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:FAYE
Last Name:LAMBERTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2407 TONY KEATING ROAD
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606
Mailing Address - Country:US
Mailing Address - Phone:662-563-0714
Mailing Address - Fax:662-563-0617
Practice Address - Street 1:2407 TONY KEATING ROAD
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606
Practice Address - Country:US
Practice Address - Phone:662-563-0714
Practice Address - Fax:662-563-0617
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP128376164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770270Medicaid